Venous access. Preoperative, operative, and postoperative dilemmas.

The past two decades have seen a tremendous increase in the use of central venous catheters and its associated complications. The increased sophistication that physicians now have with regard to nutritional and metabolic needs has escalated the use of central venous catheters. As the acquired immunodeficiency syndrome epidemic grows, so too will the number of patients with infections and metabolic complications, many of whom will have conditions severe enough to benefit from the use of central venous catheters to deliver antimicrobial drugs and other supportive intravenous therapy. Our ability to sustain patients with short-bowel syndrome also relies critically on central venous access. Likewise, treatment of patients with leukemias and certain solid tumors frequently requires placement of these catheters. Central venous catheters are essential for bone marrow transplantation. Efforts to minimize the risks associated with placement of a central venous catheter by more frequent use of catheter exchange rather than another venipuncture should be encouraged when possible. Techniques to prevent arrhythmia during overinsertion of guide wires are also important. Vigilant searches for, and prompt treatment of, catheter-related sepsis and central vein thrombosis are critical. Better prophylaxis against the development of catheter-related sepsis and catheter-related thrombosis is also needed. Further prospective investigations should be performed, however, to define precisely cost-effective methods of detection and duration of therapy for patients with both catheter-related sepsis and catheter-related thrombosis. Further advances in the technology and management of catheters need to continue to meet these ongoing challenges.